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TEAM EMERGENCY PSYCHIATRY A SURVEY DESIGNED TO ASSESS EMERGENCY PHYSICIANS’ COMFORT LEVEL IN THE MANAGEMENT OF PSYCHIATRIC PATIENTS IN THE EMERGENCY DEPARTMENT.

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Case One: Y ou are working in a rural ER when a 45 year old woman arrives with a complaint of chest pain. She was recently released from jail after being arrested for DUI. She states she has been under a lot of stress because she is going through a divorce, her children are in college, and she lives alone. In passing, she mentions that she has not been able to get out of bed for days and that her life is not worth living. Patient denies regular use of alcohol prior to the DUI. Telemedicine Psychiatry consult recommends that she be admitted. You agree that the patient needs to be admitted and complete the involuntary commitment papers. No psychiatric hospital beds are available and you are instructed to call for a bed in 3 days. Would you feel comfortable starting her on an antidepressant while she waits for admission?

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Teaching points: Case 1 Patients often experience improvement of symptoms during the first seven to ten days of initiating treatment with an antidepressant. The recommended first line treatment of Major Depressive Disorder is the SSRI’s (Selective Serotonin Reuptake Inhibitor). The correct initial treatment for this patient would be any ONE of the following: –Fluoxetine (Prozac) starting dose 20mg PO daily –Sertraline (zoloft) starting 50mg PO daily –Citalopram (Celexa)20mg PO daily

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Case Two: Refer to the previous scenario. After three days the patient is no longer reporting thoughts of hurting herself. She is not eating well, but is more animated and talking with staff. None of her psychosocial stressors have changed, but she verbalizes that she can handle it. She agrees to a safety plan of contacting her estranged sister and going to the Mental Health department as soon as she leaves the ED to arrange outpatient care. She says that she will return to the ED if she feels unsafe. Her commitment papers have expired. Would you feel comfortable discharging her for outpatient treatment rather than inpatient admission?

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Teaching points: Case 2 This patient is exhibiting “flight into wellness” which is frequently seen within 1-2 days of hospitalization, but does not indicate reduction of suicide risk. A dangerous window exists at this time during which her anxiety has improved along with her energy; however, her depression persists. This combination of increased function with persistent depression paradoxically places her at higher risk of executing her plan of suicide.

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Teaching points: Case 2, cont. There is no viable Safety Plan established to ensure her safety. Therefore she should not be discharged from the emergency department and commitment papers should be renewed if the patient is unwilling to stay.

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Case Three: A family practice physician calls to advise you that he is sending a patient to the ED due to recent worsening of psychotic symptoms. He cautions you that the patient may tell you that he does not want to be hospitalized. In the Emergency Department the patient is pleasant and cooperative. He is well oriented and reports that he has been hearing voices for several weeks, but has no suicidal or homicidal thoughts. The medical evaluation is negative and there are no psychiatric beds available. Would you feel comfortable starting this patient on antipsychotic medication and arranging for outpatient follow-up?

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Teaching points: Case 3 Worsening of psychotic symptoms can be treated on an outpatient basis as long as there are no safety issues for the patient or others. The correct initial treatment of this patient is to start an antipsychotic medication and schedule an appointment with outpatient psychiatry.

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Case Four: A 75 year old woman arrives in the ED with a delusion that her bedridden neighbor has been trying to hurt her. The police report that the patient went to her neighbor’s home with a butcher knife demanding that she stop trying to harm her. The patient was brought to the ED by police for evaluation. The patient has been medically cleared. This is a holiday week- end and there are no psychiatric beds available for at least another 3 days and no psychiatrist is on call. Would you feel comfortable starting treatment with an antipsychotic medication while this patient is waiting for involuntary admission to a psychiatric hospital?

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Teaching points: Case 4 This patient presents with psychotic symptoms. Recommended treatment is an antipsychotic medication. Since this is a geriatric patient the recommendation is to use a lower starting dose and a more gradual titration based on the patient’s symptoms and response. The following would be correct starting doses for initial treatment: –Risperdal 0.25mg PO qHS if tolerated can increase to 0.25mg PO bid in 24hours –Seroquel 25mg PO q.HS and increase to 25mg PO bid on day two. –Zyprexa 2.5mg PO q.HS and increase to 2.5mg PO bid on day two. –Haldol 2.5mg PO qHS and increase to 2.5mg PO bid on day two. (An EKG shows no QTc >450ms.)

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Case Five: A 25yo man with a previous diagnosis of schizophrenia presents disheveled, agitated, hallucinating, and requiring placement in a safety room. His agitation requires you to restrain and tranquilize him. After a period of sleep his thoughts are better organized and he reports that he has not been taking his medications as prescribed. He cannot tell you the names of his current medications. He tells you he is allergic to Haldol and you observe him to have involuntary lip smacking. There is no mental health coverage available for 3 days due to a long holiday week-end. Would you feel comfortable starting regular dosing with an antipsychotic medication rather than “PRN” dosing for agitation while he remains in your Emergency Department?

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Teaching points: Case 5 This patient has an exacerbation of his Schizophrenia and also has Tardive Dyskinesia. Correct treatment is regular dosing with an antipsychotic medication. Treatment of this patient’s symptoms is analogous to the treatment of pain. The treatment goal is a sustained control of his symptoms rather than treating exacerbations as needed. You can initiate any antipsychotic medication besides Haldol. Begin treatment with any of the following: –Risperdal 2mg PO qHS and increase to 3-4mg PO qHS on day two. –Seroquel 100mg PO qHS and increase to 300mg PO qHS on day two. –Zyprexa 5mg PO qHS and increase to 10mg PO qHS on day two. Treat extraparietal side effects with cogentin 1-2mg po per day or Benadryl 25-50mg po once per day.

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Case Six: Refer to the previous question. After 72 hours the patient no longer requires seclusion, has been taking his medications, and the commitment papers have expired. The patient reports that he continues to experience his chronic auditory hallucinations telling him to hurt others, but says that he has no intention of acting on what these voices are saying. His mother has been visiting regularly and he has an established outpatient mental health care provider. Would you feel comfortable discharging this patient for outpatient treatment?

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Teaching points: Case 6 Patients with psychotic disorders can often be stabilized with two or three days of treatment with antipsychotic medication and be safely discharged for outpatient psychiatric treatment. Patients should be prescribed a one week supply of medication and given follow up within one week. The continued presence of this patient’s auditory hallucinations does not mandate hospitalization for treatment.

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Teaching points: Case 6 This patient has a viable Safety Plan that includes: –A reliable adult who agrees to monitor the patient’s behavior and safety. –The patient agrees to outpatient psychiatric treatment upon discharge. –The patient’s thought processes are clear and he is able to reliably report no intent to harm self or others. –Patient and mother agree to return or call 911 if he worsens.

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Case Seven: You arrive for your shift on Monday morning and re- encounter a patient whom you committed on Friday before going home for a weekend off. No inpatient Psychiatric beds are available. The patient has a history of Bipolar Disorder with psychotic symptoms and when you saw her on Friday she was agitated, dysphoric, and threatening to hurt her husband. Your replacement started the patient on Depakote and Risperdal and she now reports feeling better and is no longer agitated. She reports that her thoughts of hurting her husband have not entirely resolved, but that she has no intention of acting on these thoughts. Her commitment papers have expired. Her sister is visiting. Would you feel comfortable discharging her for outpatient treatment?

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Teaching points: Case 7 This patient presents with an acute exacerbation of her Bipolar illness. Such patients can respond rapidly when given appropriate medications for their mood disorder. For acute stabilization of the symptoms of BPAD a mood stabilizer should be the first line of treatment. This can be given in combination with an antipsychotic medication and a benzodiazepine.

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Teaching points: Case 7 Disposition: This patient is no longer agitated or threatening to hurt her husband. She would be appropriate for discharge for mental health follow-up within 24hours in the care of a family member.

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Case Eight: A 42 year old man with a long history of criminal activity including Assault & Battery and a prior history of incarceration arrives intoxicated and threatening to hurt others. He states that he plans to kill his girlfriend because she has been unfaithful. He has no known psychiatric history except for Poly-Substance Dependence and Antisocial Personality Disorder. After sobering up he still states that he intends to kill his girlfriend. You page a psychiatrist who tells you that no psychiatric consult is necessary because this is a legal issue and not an acute psychiatric illness. Would you feel comfortable discharging this patient from your Emergency Department with instructions that if he hurts anyone it will be a police matter?

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Teaching points: Case 8 This patient presents with Antisocial Personality Disorder and acute intoxication. When no longer intoxicated he still threatens to harm his girlfriend. There are no symptoms of acute psychiatric illness and he does not meet criteria for involuntary commitment. Involuntary commitment criteria are that the patient has dangerousness and a mental illness. Dangerousness alone does not warrant psychiatric hospitalization.

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Teaching points: Case 8 You should report the patient’s threats to harm his girlfriend to Law-Enforcement. You are required to issue a Tarasoff warning to his girlfriend which should be documented in the ED chart.

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Case Nine: A 55yo white woman with Alcohol Dependence in Full Sustained Remission presents with a complaint of chest pain, shortness of breath, and a feeling of impending doom. This is her tenth admission to the ED for the same complaint. Her cardiac evaluation was negative on a recent visit. While you are waiting for her test results, she tells you that she is unemployed, recently lost her home, and lives in a shelter. Would you feel comfortable prescribing a benzodiazepine and arranging outpatient follow-up?

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Teaching points: Case 9 The patient presents with significant symptoms of an anxiety disorder. Her somatic symptoms are due to anxiety and she does not have a cardiovascular disorder. The correct treatment would be an anxiolytic medication. This patient has remained in Full Sustained Remission from her alcohol dependence. Therefore there is no contraindication to prescribing short term use of a benzodiazepine. The longer she remains untreated, the higher her risk of relapse.

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Teaching points: Case 9, cont. The correct treatment for this patient would include short term use of a benzodiazepine. The following would be options: –Klonopin 0.5mg PO q8hrs to 12hrs prn for anxiety. Dispense #15 tabs with no refill OR, –Ativan 0.5mg PO q8hrs to 12hrs prn for anxiety. Dispense #15 tabs with no refill. –Would not recommend short acting benzodiazepine such as xanax. The patient should be referred for Mental Health follow-up or see her PCP for referral within one week.

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Case Ten: You are working in a rural ED. A 24 year old man arrives with a complaint of abdominal pain and the medical evaluation is negative. He tells the nurse that he is anxious and depressed and later divulges that his life is not worth living. He reports that he has lost his appetite, spends a lot of time alone, and has lost interest in his previous hobbies for the past 2 months. He does not live near his family and recently broke up with his girlfriend of 6 months. Psychiatric services are not available in your hospital. Would you feel comfortable starting him on an anti- depressant and arranging for out patient follow-up?

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Teaching points: Case 10 This person presents with a 2 month history of worsening depression, recent losses and little social support. He is expressing Passive Suicidality and no safety plan can be established. He should not be discharged from the ED and an admission should be arranged to a psychiatric hospital. While awaiting admission it would be reasonable to initiate treatment with an antidepressant.